5737 Swope Parkway, Kansas City, Missouri 64130
www.bccgkc.org
Membership Application
Firm Name
Contact Rep
Position
Mailing Address
City
State
Zip Code
Phone
Fax
Email
Website
Business Description
Please do not include any special character. like (,.)
How did you learn about us?
Newspaper
Online
Referral
Other
Number of Employees
Entity Structure
Partnership
Sole Proprietorship
Corporation
S-Corp
LLP
LLC
Other
Number of Years in business
Type of Business
Auto
5511
Construction
7353
Cosmetology
7231
Entertainment
7929
Financial
6282
Healthcare
8621
Hotel / Motel
7011
Insurance
6411
Legal
8111
Manufacturer
8742
Media
3577
Printing
2759
Public Relations
8743
Public Utilities
8611
Publishing
2741
Real Estate
6351
Restaurant
5812
Retail / Wholesale
5131
Service
1799
Transportation
5088
Other
Annual Gross Income
less than $100,000
$100,000 – $500,000
$500,001 - $1,000,000
$1,000,000+
Certifications
KCMO Minority Business Enterprise (MBE)
SBA Section 8(a)
KCMO Women Business Enterprise (WBE)
Section 3
Investment Schedule
(Note: Membership dues are based on the calendar year)
Student
(Note: Requires copy of student ID or letter from educational institute on letterhead)
50
Individual
100
Non-Profit
(Note: Must submit a copy of your organization’s tax exempt letter upon approval)
Business
(Note: 1 FT employee = 2 PT employees)
300
Small Business:
10 or less employees
300
11-25 employees
400
26-50 employees
500
51-75 employees
600
76+ employees
850
Corporate
Sustaining
2,550
Silver Sustaining
5,000
Gold Sustaining
7,500
BCCGKC Committee(s)
Please select the committee(s) in which you would like to serve on.
Legislative & Public Policy
Business & Economic Development
Membership Development
Finance
Marketing/Communications/Public Relations
Programs & Activities
Fundraising
Method of payment
Check (Please make all checks payable to the Black Chamber of Commerce)
Credit Card
MasterCard
Visa
Card Holder Name
Zip Code
Card Number
Ex.Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Ex.Year
Card Holder Signature
Date
I hereby certify that the information contained herein is true and accurate to the best of my knowledge.
Signature
Date
Print Name
